Provider Demographics
NPI:1235406612
Name:LARS JOHNSON, DDS, PC
Entity Type:Organization
Organization Name:LARS JOHNSON, DDS, PC
Other - Org Name:FOREST EDGE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LARS
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-388-3289
Mailing Address - Street 1:1722 W ALGONQUIN RD
Mailing Address - Street 2:
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60192-1573
Mailing Address - Country:US
Mailing Address - Phone:847-934-8070
Mailing Address - Fax:847-934-0930
Practice Address - Street 1:1722 W ALGONQUIN RD
Practice Address - Street 2:
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60192-1573
Practice Address - Country:US
Practice Address - Phone:847-934-8070
Practice Address - Fax:847-934-0930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190264011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty